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Home > Press Center > Coronary Revascularization

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Jill Goodwin
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Researchers have found that patients with significant coronary artery disease, accompanied by either critical limb ischemia (CLI) or intermittent claudication (IC), can have vascular surgery that results in low mortality and morbidity. However, they learned that vascular surgery results for CLI and IC patients were not improved by coronary artery disease (CAD) revascularization before surgery and provided no protection from MIs or death either perioperatively or at long-term follow-up. There was no difference in long-term survival for either group.

The study, published in the June 2006 issue of the Journal of Vascular Surgery, was a sub-analysis of the Coronary Artery Revascularization Prophylaxis Trial. In the Trial, 510 patients were randomized to coronary revascularization or no revascularization, prior to elective vascular surgery. One hundred and forty-three had CLI and 164 had IC as indicators for lower limb revascularization.      

The presence of coronary artery disease was determined by cardiac catheterization and eligible patients had at least one treatable coronary lesion of 70 percent or more. These patients were followed for 2.7 years postoperatively.  

Joseph Rapp, MD, from the vascular surgery service of the San Francisco Veterans Affairs Medical Center, was a co-author of the study.      

"The IC patients had a longer time from randomization to vascular surgery and more abdominal operations," said Dr. Rapp, “while the ICL patients had more urgent operations, re-operations and limb loss, as well as longer hospital stays.

“However, the IC group had more perioperative myocardial infarctions (MI's)—17.1 percent compared to 8.4 percent of the ICL group; at follow-up, the IC group also had more MI’s (25 percent compared to the CLI group at 16.8 percent.) 

Dr. Rapp said that CLI patients are generally reported to have rates of perioperative MI at least as high as patients with IC. He noted that the increased MI’s among IC patients possibly were due to the greater number of abdominal operations they had. Both groups had a similar severity of cardiac lesions; patients with IC exhibited cardiac risk at least as high as those with CLI.  

"The severity of coronary artery disease appeared to be the primary factor determining perioperative and long-term outcomes," said Dr. Rapp. "In past studies there were better outcomes for IC due primarily to a higher prevalence of coronary artery disease among patients with CLI and the comorbities associated with CLI.  

Dr. Rapp said that researchers saw better than expected perioperative and long-term results in these high risk patients due to aggressive use of cardio-protective medications, including beta blockers, antiplatelet agents, statins, ACE inhibitors,” said Dr. Rapp. 

Researchers noted that cardiac vascularization before vascular surgery may not have improved mortality rates because of factors including: two successive major surgical procedures increase physiologic and myocardial stresses; complete revascularization is not always feasible (only two-thirds of study patients and full revascularization); unstable plaques in insignificant coronary artery lesions are unidentifiable by cardiac revascularization may become occlusive in the perioperative period and precipitate a MI;  and medical therapy used for coronary artery disease can effectively reduce the perioperative and long-term cardiac risk.